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Slide 1 :
Respiratory Failure Neurologic Emergency Lectures July 20, 2007
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Etiology Myasthenic Crisis Guillian-Barre syndrome High cervical spine injury Low cervical, thoracic spine injury Transverse myelitis Acid maltase deficiency Altered mental status Brainstem insult Motor neuron disease Botulism Tetanus Organophosphate toxicity Critical illness polyneuropathy and/or myopathy Elevated ICP Posterior fossa insult and/or operation Electrolyte abnormalities Multiple sclerosis
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Presentation Dyspnea with mild exertion Tachycardia Tachypnea Use of sternocleidomastoid, scalene muscles Forehead sweating Staccato speech Paradoxical abdominal breathing Nasal flaring Quiet speech
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Diagnosis Counting on one breath ~ 10 – FVC approximately 1 L ~ 25 – FVC approximately 2 L
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Diagnosis Assessing diaphragm function at the bedside. Ask patient to provide a sudden vigorous “sniff.” Assessing pharyngeal and respiratory muscle function at the bedside. Ask patient to take a huge breath and cough. Observe for paradoxical abdominal wall movement.
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Diagnosis Pulmonary Functions Forced vital capacity Normal 40-70 mL/kg Critical 10-15 mL/kg Negative inspiratory force Normal > - 70 cm H2O Critical > - 20 cm H2O Maximum expiratory pressure Normal > 140 cm H2O Critical > 40 cm H2O
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Diagnosis ABG Oximetry Ineffective initial diagnostic tools Late manifestation of failure
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Management BiPAP Intubation Appropriate consult Anesthesia versus medicine Early tracheostomy Treat underlying disorder Correct other comorbid conditions
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Weaning parameters PaO2 > 60 mm Hg Tidal Volume > 5 mL/kg Vital capacity > 15 mL/kg Minute ventilation > 10 L/kg Negative inspiratory force > - 40 mm Hg
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TreatmentMyasthenia Gravis Anticholinesterase medications held initially Reinstated gradually Plasmapheresis ( x 5 exchanges) IVIg 0.4 g/kg x 5 days Consider steroids if no initial improvement Correct electrolyte disturbances Treat infections Avoid aminoglycosides, quinolones, tetracyclines, clindamycin
Slide 11 :
Case 1 55 year-old man with myasthenia gravis presents to the ED with 24 hours of restlesness, inability to sleep, and altered mental status. Medications: Mestinon 60 mg PO q6 hours while awake (TID) Mestinon TS 240 mg PO qhs Prednisone 3 mg PO qod
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Case 1 On examination, he is in mild distress. He is confused and disoriented. He can only provide poor cough and sniff attempts. There is a sunken appearance to the abdomen during inspiration. He can count to 12 on one breath. The pupils react from 4.0mm to 2.5mm OU. There is mild bilateral ptosis, bifacial weakness, mild gutteral dysarthria.
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Case 1 Temp 98.9 HR 100 RR 30 BP 110/72 Oxygen saturation 97% on 1L ABG with mildly increased pCO2, normal pO2 Chest radiography shows bibasilar atelectiasis vs. bibasilar infiltrates
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Case 1 Diagnosis? Management?
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Case 1 Diagnosis? Acute Myasthenic Crisis Impending respiratory failure Management? Emergent intubation Cessation of Mestinon initially, followed by slowly restarting Immunotherapy with plasmapheresis or intravenous immunoglobulin
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Case 2 47 year-old woman with myasthenia gravis and chronic renal insufficiency presents in acute, severe respiratory distress. Medications: Mestinon 120 mg PO TID Mestinon TS 240 mg PO qhs
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Case 2 On examination, she is in severe distress and diaphoretic. She can only provide poor cough and sniff attempts. Her secretions are copious. There is a sunken appearance to the abdomen during inspiration. The pupils are 1.5mm and reactive. There is mild bilateral ptosis, bifacial weakness, moderate gutteral and labial dysarthria.
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Case 2 Temp 98.9 HR 110 RR 36 BP 110/72 Oxygen saturation 96% on 4L NRB ABG with mildly increased pCO2, normal pO2 Chest radiography shows bibasilar atelectiasis vs. bibasilar infiltrates Creatinine is 2.9 (baseline 1.8)
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Case 2 You speak with the family. They tell you that the patient has been having abdominal cramping, nausea, vomiting, and diarrhea for 2-3 days.
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Case 2 Diagnosis? Management?
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Case 2 Diagnosis? Acute Cholinergic Crisis Acute renal failure has resulted in decreased clearance of Mestinon. Management? Emergent intubation Cessation of Mestinon (temporarily)
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Case 3 48 year-old woman with myasthenia gravis admitted for worsening
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55 year-old man with myasthenia gravis presents to the ED with 24 hours of47 year-old woman with my
55 year-old man with myasthenia gravis presents to the ED with 24 hours of47 year-old woman with myasthenia gravis and chronic renal insufficiency …